SlideShare a Scribd company logo
Clive Bates
Counterfactual 1
Nairobi
1 December 2022
Science behind Tobacco Harm Reduction …and how
it impacts policy development and regulation
The Harm Reduction Exchange
2022
2
I am a former director of Action on Smoking and Health (UK)
I have supported tobacco harm reduction since 1997
I have no competing interests with respect to the tobacco, e-
cigarette, or pharmaceutical industries
Regulation for tobacco harm reduction
1. The problem is smoking
3
Well researched toll of harm from smoking…
Smoking prematurely
kills around 8 million
annually
…more than obesity,
alcohol, road accidents,
drug misuse and HIV
combined
4
Public Health England, Health Matters
…similar to COVID-19,
but every year
Smoking prevalence in Africa – WHO (2021)
5
Published November 2021 South Africa
Nigeria
Ethiopia
Smoking prevalence in Africa – WHO (2021)
6
Published November 2021
South Africa
Ethiopia
Nigeria
Declining prevalence but increasing population will increase African share
7
Africa
Regulation for tobacco harm reduction
1. The problem is smoking
2. Smoke-free alternatives
8
“People smoke for
the nicotine but
die from the tar”
(1976)
Professor Michael Russell 1932-2009
The central insight in smoking and health
9
Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:1430–3
Smokeless tobacco
Tobacco based
Pure nicotine based
Heated
aerosol
Unheated
Vaping products Heated tobacco products
“Heat-not-burn”
Items are not shown to scale
Oral nicotine products
10
Royal College of Physicians – on relative risk
"Although it is not possible to
precisely quantify the long-
term health risks associated
with e-cigarettes, the
available data suggest that
they are unlikely to exceed
5% of those associated with
smoked tobacco products,
and may well be substantially
lower than this figure".
11
Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
Department of Health (England) – on relative risk September 2022
12
McNeill et al. Nicotine Vaping in England, 2022
“…vaping poses only a
small fraction of the risks
of smoking”
Much
lower
Much
lower
Much
lower
Much
lower
Much
lower
Much
lower
The strongest evidence for reduced harm is reduced exposure
13
Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and
Nicotine Replacement Therapy Users. Ann Intern Med 2017
Evidence from randomised controlled trials
14
“There is high‐certainty
evidence that e-
cigarettes with nicotine
increase quit rates
compared to NRT”
Evidence for beneficial population effect ‘triangulates’
• Also, user testimony
• And… it is what you would expect!!
15
Professor Robert West, UCL. Presentation at SRNT-Europe 2019
Regulation for tobacco harm reduction
1. The problem is smoking
2. Smoke-free alternatives
3. Policy and unintended consequences
16
The public health mechanism
17
Royal College of Physicians – perverse unintended consequences
18
Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
…if a risk-averse, precautionary approach
makes e-cigarettes:
• less easily accessible
• less palatable or acceptable
• more expensive
• less consumer friendly
• pharmacologically less effective
• inhibits innovation …
…then it causes harm by perpetuating
smoking.
Royal College of Physicians – perverse unintended consequences
19
Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
1. Prohibition of vaping and other smokefree products
1. Prohibition of vaping and other smokefree products
“Dr Harsh Vardhan received the
award for spearheading the
Government of India’s legislation
to ban e-cigarettes and heated
tobacco products in 2019.”
1. Prohibition of vaping and other smokefree products
22
Today, the country is faced with a
greater challenge, that of illegal
traffic in tobacco and its products.
So long as the demand within the
country persists, it will continue to
fuel the illicit market that has
expanded since the ban of its sale in
early 2000.
Unfortunately, as studies indicate,
Bhutanese youth are at the centre
of this growing illegal trade in
tobacco and its products.
WHO Office Bhutan: The Big Ban: Bhutan’s journey towards a tobacco-free society, 2019
2. Banning e-liquid flavours
23
2. Banning e-liquid flavours
Tobacco
Fruit
Dessert
or pastry
Choc,
sweets
Russell et al. vaping
flavour preferences
Russell C, et al. Changing patterns of first e-cigarette flavor used and current flavors used by
20,836 adult frequent e-cigarette users in the USA. Harm Reduct J. BioMed Central; 2018 24
2. Banning e-liquid flavours
25
• The intended outcome: abstinence from nicotine, vaping, smoking and any other vice
• Using tobacco flavoured vape products instead of other flavoured products
• Accessing flavoured vapes via an illicit supply chain (a black market)
• Relapsing back from vaping to smoking – both teenagers and adults
• Not switching from smoking to vaping and continuing to smoke
• Continuing to smoke or to start smoking as an adolescent because parents or adult role models smoke instead of vaping
• Using other tobacco or nicotine products – hand-rolling tobacco, smokeless tobacco, heated tobacco, or new nicotine pouches
• Buying from foreign suppliers in person or via the internet and importing for personal use
• Buying from foreign suppliers to resell to others through informal networks
• Making and mixing their own flavours at home or buying or selling home-mixed flavours
• Using vapes that are made to look tobacco flavoured but have other flavours
• Using flavour agents for food, drink or aromatherapy for adding to unflavoured nicotine liquids
• Using flavours made for vaping but ostensibly marketed for another purpose
• Switching to cannabinoid (THC or CBD) vapes
• Initiating smoking instead of initiating vaping
• Adopting another risk behaviour that may be worse
Friedman AS. A Difference-in-Differences Analysis of Youth Smoking and a Ban on Sales of Flavored Tobacco Products in San
Francisco, California. JAMA Pediatrics. 2021
2. Banning e-liquid flavours
Teenage smoking
increased following an
e-cigarette flavours ban
in San Francisco
Past-30-Day Smoking Trends Among High School Students Younger Than 18
Years
3. Banning advertising of vapes
27
3. Banning advertising of vapes
28
3. Banning advertising of vapes
29
 Don’t be socially irresponsible
 Don’t target or feature children
 Don’t confuse e-cigarettes with tobacco products
 Don’t make health or safety claims
 Don’t make smoking cessation claims
 Don’t mislead about product ingredients
 Don’t mislead about where products may be use
Set standards avoid bans
4. Fear-based warnings
This product contains
nicotine which is a highly
addictive substance.
30
Required by EU Tobacco Products Directive 40/14/EU
4. Fear-based warnings
“[Our findings] suggest that the
TPD nicotine addiction e-cigarette
health warning may reduce
smokers' willingness to use, and
likelihood of purchasing an e-
cigarette.”
31
Cox S, et al Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative
relative risk message on smokers’ willingness to use and purchase an electronic cigarette. Addict Behav Reports, 2018
This product is likely to
be at least 95% safer
than smoking cigarettes
No product is completely
safe, but use of this
product is much less
harmful than smoking
4. Fear-based warnings
32
5. Taxing safer products
5. Taxing safer products
• Reduce teen e-cigarette use by 2.7 percentage
points, but that 2 in 3 teens who do not use e-
cigarettes due to the tax would smoke
cigarettes instead.
• ….approximately a half million extra teenage
smokers overall.
• … raise the number of daily adult cigarette
smokers by 2.5 million nationally and reduce
adult e-cigarette users by a similar number.
• For every e-cigarette pod eliminated by an e-
cigarette tax, more than 5.5 extra packs of
cigarettes are sold instead
Congress: raise e-cigarette taxes to a level
comparable to cigarette taxes…
5. Taxing safer products
The solution: Risk-Proportionate Regulation
Measure Cigarettes, hand-rolling tobacco and other
combustibles
Taxation Relatively high taxes
Advertising Prohibit other than within trade
Warnings Graphic warnings depicting disease
Public places Legally mandated controls
Plain packaging Yes
Ingredients Control reward-enhancing additives
Age restrictions No sales to under-21s
Internet sales Banned
Product standards Control risks and reduce appeal
36
The solution: Risk-Proportionate Regulation
Measure Cigarettes, hand-rolling tobacco and other
combustibles
Vaping, heated tobacco smokeless and oral
nicotine
Taxation Relatively high taxes Low or zero tax (sales tax only)
Advertising Prohibit other than within trade Control themes and placement
Warnings Graphic warnings depicting disease Messages encouraging switching
Public places Legally mandated controls Up to the discretion of the owner
Plain packaging Yes No
Ingredients Control reward-enhancing additives Blacklist material health hazards
Age restrictions No sales to under-21s No sales to under-18s
Internet sales Banned Permitted with age controls
Product standards Control risks and reduce appeal Control risks
37
Regulations for tobacco harm reduction
1. The problem is smoking
2. Smoke-free alternatives
3. Policy and unintended consequences
4. Innovation (and its enemies)
38
A technology transition - cars
A technology transition - electricity
Innovation and its enemies…
“Claims about the promise of new technology are at times greeted with
skepticism, vilification or outright opposition—often dominated by slander,
innuendo, scare tactics, conspiracy theories and misinformation.
“The assumption that new technologies carry unknown risks guides much of
the debate. This is often amplified to levels that overshadow the dangers of
known risks.”
Juma C. Innovation and Its Enemies: Why People Resist New Technologies. Oxford, New York: Oxford University Press; 2016.
Thankyou!
Counterfactual
clivedbates@gmail.com
www.clivebates.com
@clive_bates
1. The problem is smoking
2. Smoke-free alternatives
3. Policy and unintended consequences
4. Innovation (and its enemies)
Regulation for tobacco harm reduction

More Related Content

Similar to African Harm Reduction Exchange - Dec 2022

Beyond Cigarettes: The Risks of Non-Cigarette Nicotine Products and Implicati...
Beyond Cigarettes: The Risks of Non-Cigarette Nicotine Products and Implicati...Beyond Cigarettes: The Risks of Non-Cigarette Nicotine Products and Implicati...
Beyond Cigarettes: The Risks of Non-Cigarette Nicotine Products and Implicati...
Center on Addiction
 
Tobacco harm reduction - meetings with Hill staff
Tobacco harm reduction - meetings with Hill staff Tobacco harm reduction - meetings with Hill staff
Tobacco harm reduction - meetings with Hill staff
Clive Bates
 
E-cigarettes: pros, cons and controversy
E-cigarettes: pros, cons and controversy E-cigarettes: pros, cons and controversy
E-cigarettes: pros, cons and controversy
Laura-Jane Smith
 
Respect Vapers Ireland - webinar on tobacco harm reduction
Respect Vapers Ireland - webinar on tobacco harm reductionRespect Vapers Ireland - webinar on tobacco harm reduction
Respect Vapers Ireland - webinar on tobacco harm reduction
Clive Bates
 
Why is FDA regulation such a mess
Why is FDA regulation such a messWhy is FDA regulation such a mess
Why is FDA regulation such a mess
Clive Bates
 
B Healthy Webinar Smoking
B Healthy Webinar SmokingB Healthy Webinar Smoking
B Healthy Webinar Smoking
HealthyBrum
 
The end of what? UK E-cigarette Summit 2023
The end of what? UK E-cigarette Summit 2023The end of what? UK E-cigarette Summit 2023
The end of what? UK E-cigarette Summit 2023
Clive Bates
 
GASO 11.20.2014 - The Tobacco Epidemic in the 21st Century
GASO 11.20.2014 - The Tobacco Epidemic in the 21st CenturyGASO 11.20.2014 - The Tobacco Epidemic in the 21st Century
GASO 11.20.2014 - The Tobacco Epidemic in the 21st Century
Georgia State School of Public Health
 
Science based policy or policy based science?
Science based policy or policy based science?Science based policy or policy based science?
Science based policy or policy based science?
Clive Bates
 
Effects of alternative nicotine delivery systems on cigarette consumption and...
Effects of alternative nicotine delivery systems on cigarette consumption and...Effects of alternative nicotine delivery systems on cigarette consumption and...
Effects of alternative nicotine delivery systems on cigarette consumption and...
Clive Bates
 
Tobacco Harm Reduction_Crimson Publishers
Tobacco Harm Reduction_Crimson PublishersTobacco Harm Reduction_Crimson Publishers
Tobacco Harm Reduction_Crimson Publishers
CrimsonpublishersTTEH
 
FDLI - Lesson for the US from other jurisdictions - the United Kingdom -29 Oc...
FDLI - Lesson for the US from other jurisdictions - the United Kingdom -29 Oc...FDLI - Lesson for the US from other jurisdictions - the United Kingdom -29 Oc...
FDLI - Lesson for the US from other jurisdictions - the United Kingdom -29 Oc...
Clive Bates
 
Asia House - Six insights into tobacco harm reduction
Asia House - Six insights into tobacco harm reductionAsia House - Six insights into tobacco harm reduction
Asia House - Six insights into tobacco harm reduction
Clive Bates
 
Smoking cesseation
Smoking cesseationSmoking cesseation
Smoking cesseation
bayapreddy
 
Accelerating the National Progress to Reduce Tobacco Use
Accelerating the National Progress to Reduce Tobacco UseAccelerating the National Progress to Reduce Tobacco Use
Accelerating the National Progress to Reduce Tobacco Use
Georgia State School of Public Health
 
Nicotina - Reducción de riesgos y daños / Nicotine - Risk and Harm Reduction
Nicotina - Reducción de riesgos y daños / Nicotine - Risk and Harm ReductionNicotina - Reducción de riesgos y daños / Nicotine - Risk and Harm Reduction
Nicotina - Reducción de riesgos y daños / Nicotine - Risk and Harm Reduction
Clive Bates
 
Burden ppt final for stakeholder group
Burden ppt final for stakeholder groupBurden ppt final for stakeholder group
Burden ppt final for stakeholder group
Brandon Williams
 
Global Forum on Nicotine 2016: What would good regulation look like
Global Forum on Nicotine 2016: What would good regulation look likeGlobal Forum on Nicotine 2016: What would good regulation look like
Global Forum on Nicotine 2016: What would good regulation look like
Clive Bates
 
The Endgame Revisited - US E-cigarette Summit 2021
The Endgame Revisited - US E-cigarette Summit 2021The Endgame Revisited - US E-cigarette Summit 2021
The Endgame Revisited - US E-cigarette Summit 2021
Clive Bates
 
Seven insights into tobacco harm reduction
Seven insights into tobacco harm reductionSeven insights into tobacco harm reduction
Seven insights into tobacco harm reduction
Clive Bates
 

Similar to African Harm Reduction Exchange - Dec 2022 (20)

Beyond Cigarettes: The Risks of Non-Cigarette Nicotine Products and Implicati...
Beyond Cigarettes: The Risks of Non-Cigarette Nicotine Products and Implicati...Beyond Cigarettes: The Risks of Non-Cigarette Nicotine Products and Implicati...
Beyond Cigarettes: The Risks of Non-Cigarette Nicotine Products and Implicati...
 
Tobacco harm reduction - meetings with Hill staff
Tobacco harm reduction - meetings with Hill staff Tobacco harm reduction - meetings with Hill staff
Tobacco harm reduction - meetings with Hill staff
 
E-cigarettes: pros, cons and controversy
E-cigarettes: pros, cons and controversy E-cigarettes: pros, cons and controversy
E-cigarettes: pros, cons and controversy
 
Respect Vapers Ireland - webinar on tobacco harm reduction
Respect Vapers Ireland - webinar on tobacco harm reductionRespect Vapers Ireland - webinar on tobacco harm reduction
Respect Vapers Ireland - webinar on tobacco harm reduction
 
Why is FDA regulation such a mess
Why is FDA regulation such a messWhy is FDA regulation such a mess
Why is FDA regulation such a mess
 
B Healthy Webinar Smoking
B Healthy Webinar SmokingB Healthy Webinar Smoking
B Healthy Webinar Smoking
 
The end of what? UK E-cigarette Summit 2023
The end of what? UK E-cigarette Summit 2023The end of what? UK E-cigarette Summit 2023
The end of what? UK E-cigarette Summit 2023
 
GASO 11.20.2014 - The Tobacco Epidemic in the 21st Century
GASO 11.20.2014 - The Tobacco Epidemic in the 21st CenturyGASO 11.20.2014 - The Tobacco Epidemic in the 21st Century
GASO 11.20.2014 - The Tobacco Epidemic in the 21st Century
 
Science based policy or policy based science?
Science based policy or policy based science?Science based policy or policy based science?
Science based policy or policy based science?
 
Effects of alternative nicotine delivery systems on cigarette consumption and...
Effects of alternative nicotine delivery systems on cigarette consumption and...Effects of alternative nicotine delivery systems on cigarette consumption and...
Effects of alternative nicotine delivery systems on cigarette consumption and...
 
Tobacco Harm Reduction_Crimson Publishers
Tobacco Harm Reduction_Crimson PublishersTobacco Harm Reduction_Crimson Publishers
Tobacco Harm Reduction_Crimson Publishers
 
FDLI - Lesson for the US from other jurisdictions - the United Kingdom -29 Oc...
FDLI - Lesson for the US from other jurisdictions - the United Kingdom -29 Oc...FDLI - Lesson for the US from other jurisdictions - the United Kingdom -29 Oc...
FDLI - Lesson for the US from other jurisdictions - the United Kingdom -29 Oc...
 
Asia House - Six insights into tobacco harm reduction
Asia House - Six insights into tobacco harm reductionAsia House - Six insights into tobacco harm reduction
Asia House - Six insights into tobacco harm reduction
 
Smoking cesseation
Smoking cesseationSmoking cesseation
Smoking cesseation
 
Accelerating the National Progress to Reduce Tobacco Use
Accelerating the National Progress to Reduce Tobacco UseAccelerating the National Progress to Reduce Tobacco Use
Accelerating the National Progress to Reduce Tobacco Use
 
Nicotina - Reducción de riesgos y daños / Nicotine - Risk and Harm Reduction
Nicotina - Reducción de riesgos y daños / Nicotine - Risk and Harm ReductionNicotina - Reducción de riesgos y daños / Nicotine - Risk and Harm Reduction
Nicotina - Reducción de riesgos y daños / Nicotine - Risk and Harm Reduction
 
Burden ppt final for stakeholder group
Burden ppt final for stakeholder groupBurden ppt final for stakeholder group
Burden ppt final for stakeholder group
 
Global Forum on Nicotine 2016: What would good regulation look like
Global Forum on Nicotine 2016: What would good regulation look likeGlobal Forum on Nicotine 2016: What would good regulation look like
Global Forum on Nicotine 2016: What would good regulation look like
 
The Endgame Revisited - US E-cigarette Summit 2021
The Endgame Revisited - US E-cigarette Summit 2021The Endgame Revisited - US E-cigarette Summit 2021
The Endgame Revisited - US E-cigarette Summit 2021
 
Seven insights into tobacco harm reduction
Seven insights into tobacco harm reductionSeven insights into tobacco harm reduction
Seven insights into tobacco harm reduction
 

More from Clive Bates

FDLI Annual 2024: seven reasons why the litigation will never stop
FDLI Annual 2024: seven reasons why the litigation will never stopFDLI Annual 2024: seven reasons why the litigation will never stop
FDLI Annual 2024: seven reasons why the litigation will never stop
Clive Bates
 
US E-cigarette Summit: Taming the nicotine industrial complex
US E-cigarette Summit: Taming the nicotine industrial complexUS E-cigarette Summit: Taming the nicotine industrial complex
US E-cigarette Summit: Taming the nicotine industrial complex
Clive Bates
 
The APPH Standard: What Does it Actually Mean?
The APPH Standard:  What Does it Actually Mean?The APPH Standard:  What Does it Actually Mean?
The APPH Standard: What Does it Actually Mean?
Clive Bates
 
Rethinking nicotine: illusions, delusions and some conclusions
Rethinking nicotine: illusions, delusions and some conclusionsRethinking nicotine: illusions, delusions and some conclusions
Rethinking nicotine: illusions, delusions and some conclusions
Clive Bates
 
Albania National Association of Public health - Harm Reduction Conference
Albania National Association of Public health - Harm Reduction ConferenceAlbania National Association of Public health - Harm Reduction Conference
Albania National Association of Public health - Harm Reduction Conference
Clive Bates
 
Vaping and tobacco: six things you need to know about harm reduction
Vaping and tobacco:  six things you need to know about harm reductionVaping and tobacco:  six things you need to know about harm reduction
Vaping and tobacco: six things you need to know about harm reduction
Clive Bates
 
The MRTP process - Seven provocations - FDLI webinar 30 July 2020
The MRTP process - Seven provocations - FDLI webinar 30 July 2020The MRTP process - Seven provocations - FDLI webinar 30 July 2020
The MRTP process - Seven provocations - FDLI webinar 30 July 2020
Clive Bates
 
Bad science - 10 insights for advocates
Bad science - 10 insights for advocatesBad science - 10 insights for advocates
Bad science - 10 insights for advocates
Clive Bates
 
Tobacco harm reduction in the UK: e-cigarettes (EC) are making a difference
Tobacco harm reduction in the UK: e-cigarettes (EC) are making a differenceTobacco harm reduction in the UK: e-cigarettes (EC) are making a difference
Tobacco harm reduction in the UK: e-cigarettes (EC) are making a difference
Clive Bates
 
Regulation of Tobacco Harm Reduction - GFN 2018 Scholars
Regulation of Tobacco Harm Reduction - GFN 2018 ScholarsRegulation of Tobacco Harm Reduction - GFN 2018 Scholars
Regulation of Tobacco Harm Reduction - GFN 2018 Scholars
Clive Bates
 
E-cigarette Summit US presentation 2018
E-cigarette Summit US presentation 2018E-cigarette Summit US presentation 2018
E-cigarette Summit US presentation 2018
Clive Bates
 
What would good regulation look like?
What would good regulation look like?What would good regulation look like?
What would good regulation look like?
Clive Bates
 

More from Clive Bates (12)

FDLI Annual 2024: seven reasons why the litigation will never stop
FDLI Annual 2024: seven reasons why the litigation will never stopFDLI Annual 2024: seven reasons why the litigation will never stop
FDLI Annual 2024: seven reasons why the litigation will never stop
 
US E-cigarette Summit: Taming the nicotine industrial complex
US E-cigarette Summit: Taming the nicotine industrial complexUS E-cigarette Summit: Taming the nicotine industrial complex
US E-cigarette Summit: Taming the nicotine industrial complex
 
The APPH Standard: What Does it Actually Mean?
The APPH Standard:  What Does it Actually Mean?The APPH Standard:  What Does it Actually Mean?
The APPH Standard: What Does it Actually Mean?
 
Rethinking nicotine: illusions, delusions and some conclusions
Rethinking nicotine: illusions, delusions and some conclusionsRethinking nicotine: illusions, delusions and some conclusions
Rethinking nicotine: illusions, delusions and some conclusions
 
Albania National Association of Public health - Harm Reduction Conference
Albania National Association of Public health - Harm Reduction ConferenceAlbania National Association of Public health - Harm Reduction Conference
Albania National Association of Public health - Harm Reduction Conference
 
Vaping and tobacco: six things you need to know about harm reduction
Vaping and tobacco:  six things you need to know about harm reductionVaping and tobacco:  six things you need to know about harm reduction
Vaping and tobacco: six things you need to know about harm reduction
 
The MRTP process - Seven provocations - FDLI webinar 30 July 2020
The MRTP process - Seven provocations - FDLI webinar 30 July 2020The MRTP process - Seven provocations - FDLI webinar 30 July 2020
The MRTP process - Seven provocations - FDLI webinar 30 July 2020
 
Bad science - 10 insights for advocates
Bad science - 10 insights for advocatesBad science - 10 insights for advocates
Bad science - 10 insights for advocates
 
Tobacco harm reduction in the UK: e-cigarettes (EC) are making a difference
Tobacco harm reduction in the UK: e-cigarettes (EC) are making a differenceTobacco harm reduction in the UK: e-cigarettes (EC) are making a difference
Tobacco harm reduction in the UK: e-cigarettes (EC) are making a difference
 
Regulation of Tobacco Harm Reduction - GFN 2018 Scholars
Regulation of Tobacco Harm Reduction - GFN 2018 ScholarsRegulation of Tobacco Harm Reduction - GFN 2018 Scholars
Regulation of Tobacco Harm Reduction - GFN 2018 Scholars
 
E-cigarette Summit US presentation 2018
E-cigarette Summit US presentation 2018E-cigarette Summit US presentation 2018
E-cigarette Summit US presentation 2018
 
What would good regulation look like?
What would good regulation look like?What would good regulation look like?
What would good regulation look like?
 

Recently uploaded

Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga
 
Applications of NMR in Protein Structure Prediction.pptx
Applications of NMR in Protein Structure Prediction.pptxApplications of NMR in Protein Structure Prediction.pptx
Applications of NMR in Protein Structure Prediction.pptx
Anagha R Anil
 
Call Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Call Girls In Mumbai +91-7426014248 High Profile Call Girl MumbaiCall Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Call Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Mobile Problem
 
2nd-generation Antihistaminic Part I.pptx
2nd-generation Antihistaminic Part I.pptx2nd-generation Antihistaminic Part I.pptx
2nd-generation Antihistaminic Part I.pptx
Madhumita Dixit
 
Pharmacology of Drugs for Congestive Heart Failure
Pharmacology of Drugs for Congestive Heart FailurePharmacology of Drugs for Congestive Heart Failure
Pharmacology of Drugs for Congestive Heart Failure
Dr. Nikhilkumar Sakle
 
PGx Analysis in VarSeq: A User’s Perspective
PGx Analysis in VarSeq: A User’s PerspectivePGx Analysis in VarSeq: A User’s Perspective
PGx Analysis in VarSeq: A User’s Perspective
Golden Helix
 
Public Health Lecture 4 Social Sciences and Public Health
Public Health Lecture 4 Social Sciences and Public HealthPublic Health Lecture 4 Social Sciences and Public Health
Public Health Lecture 4 Social Sciences and Public Health
phuakl
 
Allopurinol (Anti-gout drug).pptx
Allopurinol (Anti-gout drug).pptxAllopurinol (Anti-gout drug).pptx
Allopurinol (Anti-gout drug).pptx
Madhumita Dixit
 
ℂall Girls 𝕀ndore ( 000000000 ) 𝕍𝕚𝕡 ℂall girl Indore
ℂall Girls 𝕀ndore ( 000000000 ) 𝕍𝕚𝕡 ℂall girl Indore ℂall Girls 𝕀ndore ( 000000000 ) 𝕍𝕚𝕡 ℂall girl Indore
ℂall Girls 𝕀ndore ( 000000000 ) 𝕍𝕚𝕡 ℂall girl Indore
babesbookhot
 
Unlimited Fun With Call Girls Gurgaon ✅ 9711199012 💘 FULL CASH PAYMENT
Unlimited Fun With Call Girls Gurgaon ✅ 9711199012 💘 FULL CASH PAYMENTUnlimited Fun With Call Girls Gurgaon ✅ 9711199012 💘 FULL CASH PAYMENT
Unlimited Fun With Call Girls Gurgaon ✅ 9711199012 💘 FULL CASH PAYMENT
keshavtiwari584
 
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)
GeorgeKieling1
 
Selective α1-Blocker.pptx
Selective α1-Blocker.pptxSelective α1-Blocker.pptx
Selective α1-Blocker.pptx
Madhumita Dixit
 
Nano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory projectNano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory project
SIVAVINAYAKPK
 
Pharmacology of Prostaglandins, Thromboxanes and Leukotrienes
Pharmacology of Prostaglandins, Thromboxanes and LeukotrienesPharmacology of Prostaglandins, Thromboxanes and Leukotrienes
Pharmacology of Prostaglandins, Thromboxanes and Leukotrienes
Dr. Nikhilkumar Sakle
 
biomechanics of running. Dr.dhwani.pptx
biomechanics of running.   Dr.dhwani.pptxbiomechanics of running.   Dr.dhwani.pptx
biomechanics of running. Dr.dhwani.pptx
Dr. Dhwani kawedia
 
pharmacy exam preparation for undergradute students.pptx
pharmacy exam preparation for undergradute students.pptxpharmacy exam preparation for undergradute students.pptx
pharmacy exam preparation for undergradute students.pptx
AdugnaWari
 
Breast cancer :hormonal discordance.pptx
Breast cancer :hormonal discordance.pptxBreast cancer :hormonal discordance.pptx
Breast cancer :hormonal discordance.pptx
Dr. Sumit KUMAR
 
One piece compressive Dental implant : data from Google Scholar
One piece  compressive  Dental implant : data from Google Scholar One piece  compressive  Dental implant : data from Google Scholar
One piece compressive Dental implant : data from Google Scholar
rafadjoko11
 
Ageing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public HealthAgeing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public Health
phuakl
 
Microbiology & Parasitology Exercises Parts of the Microscope
Microbiology & Parasitology Exercises Parts of the MicroscopeMicrobiology & Parasitology Exercises Parts of the Microscope
Microbiology & Parasitology Exercises Parts of the Microscope
ThaShee2
 

Recently uploaded (20)

Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdfOsvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
Osvaldo Bernardo Muchanga-GASTROINTESTINAL INFECTIONS AND GASTRITIS-2024.pdf
 
Applications of NMR in Protein Structure Prediction.pptx
Applications of NMR in Protein Structure Prediction.pptxApplications of NMR in Protein Structure Prediction.pptx
Applications of NMR in Protein Structure Prediction.pptx
 
Call Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Call Girls In Mumbai +91-7426014248 High Profile Call Girl MumbaiCall Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
Call Girls In Mumbai +91-7426014248 High Profile Call Girl Mumbai
 
2nd-generation Antihistaminic Part I.pptx
2nd-generation Antihistaminic Part I.pptx2nd-generation Antihistaminic Part I.pptx
2nd-generation Antihistaminic Part I.pptx
 
Pharmacology of Drugs for Congestive Heart Failure
Pharmacology of Drugs for Congestive Heart FailurePharmacology of Drugs for Congestive Heart Failure
Pharmacology of Drugs for Congestive Heart Failure
 
PGx Analysis in VarSeq: A User’s Perspective
PGx Analysis in VarSeq: A User’s PerspectivePGx Analysis in VarSeq: A User’s Perspective
PGx Analysis in VarSeq: A User’s Perspective
 
Public Health Lecture 4 Social Sciences and Public Health
Public Health Lecture 4 Social Sciences and Public HealthPublic Health Lecture 4 Social Sciences and Public Health
Public Health Lecture 4 Social Sciences and Public Health
 
Allopurinol (Anti-gout drug).pptx
Allopurinol (Anti-gout drug).pptxAllopurinol (Anti-gout drug).pptx
Allopurinol (Anti-gout drug).pptx
 
ℂall Girls 𝕀ndore ( 000000000 ) 𝕍𝕚𝕡 ℂall girl Indore
ℂall Girls 𝕀ndore ( 000000000 ) 𝕍𝕚𝕡 ℂall girl Indore ℂall Girls 𝕀ndore ( 000000000 ) 𝕍𝕚𝕡 ℂall girl Indore
ℂall Girls 𝕀ndore ( 000000000 ) 𝕍𝕚𝕡 ℂall girl Indore
 
Unlimited Fun With Call Girls Gurgaon ✅ 9711199012 💘 FULL CASH PAYMENT
Unlimited Fun With Call Girls Gurgaon ✅ 9711199012 💘 FULL CASH PAYMENTUnlimited Fun With Call Girls Gurgaon ✅ 9711199012 💘 FULL CASH PAYMENT
Unlimited Fun With Call Girls Gurgaon ✅ 9711199012 💘 FULL CASH PAYMENT
 
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)
 
Selective α1-Blocker.pptx
Selective α1-Blocker.pptxSelective α1-Blocker.pptx
Selective α1-Blocker.pptx
 
Nano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory projectNano-gold for Cancer Therapy chemistry investigatory project
Nano-gold for Cancer Therapy chemistry investigatory project
 
Pharmacology of Prostaglandins, Thromboxanes and Leukotrienes
Pharmacology of Prostaglandins, Thromboxanes and LeukotrienesPharmacology of Prostaglandins, Thromboxanes and Leukotrienes
Pharmacology of Prostaglandins, Thromboxanes and Leukotrienes
 
biomechanics of running. Dr.dhwani.pptx
biomechanics of running.   Dr.dhwani.pptxbiomechanics of running.   Dr.dhwani.pptx
biomechanics of running. Dr.dhwani.pptx
 
pharmacy exam preparation for undergradute students.pptx
pharmacy exam preparation for undergradute students.pptxpharmacy exam preparation for undergradute students.pptx
pharmacy exam preparation for undergradute students.pptx
 
Breast cancer :hormonal discordance.pptx
Breast cancer :hormonal discordance.pptxBreast cancer :hormonal discordance.pptx
Breast cancer :hormonal discordance.pptx
 
One piece compressive Dental implant : data from Google Scholar
One piece  compressive  Dental implant : data from Google Scholar One piece  compressive  Dental implant : data from Google Scholar
One piece compressive Dental implant : data from Google Scholar
 
Ageing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public HealthAgeing, the Elderly, Gerontology and Public Health
Ageing, the Elderly, Gerontology and Public Health
 
Microbiology & Parasitology Exercises Parts of the Microscope
Microbiology & Parasitology Exercises Parts of the MicroscopeMicrobiology & Parasitology Exercises Parts of the Microscope
Microbiology & Parasitology Exercises Parts of the Microscope
 

African Harm Reduction Exchange - Dec 2022

  • 1. Clive Bates Counterfactual 1 Nairobi 1 December 2022 Science behind Tobacco Harm Reduction …and how it impacts policy development and regulation The Harm Reduction Exchange 2022
  • 2. 2 I am a former director of Action on Smoking and Health (UK) I have supported tobacco harm reduction since 1997 I have no competing interests with respect to the tobacco, e- cigarette, or pharmaceutical industries
  • 3. Regulation for tobacco harm reduction 1. The problem is smoking 3
  • 4. Well researched toll of harm from smoking… Smoking prematurely kills around 8 million annually …more than obesity, alcohol, road accidents, drug misuse and HIV combined 4 Public Health England, Health Matters …similar to COVID-19, but every year
  • 5. Smoking prevalence in Africa – WHO (2021) 5 Published November 2021 South Africa Nigeria Ethiopia
  • 6. Smoking prevalence in Africa – WHO (2021) 6 Published November 2021 South Africa Ethiopia Nigeria
  • 7. Declining prevalence but increasing population will increase African share 7 Africa
  • 8. Regulation for tobacco harm reduction 1. The problem is smoking 2. Smoke-free alternatives 8
  • 9. “People smoke for the nicotine but die from the tar” (1976) Professor Michael Russell 1932-2009 The central insight in smoking and health 9 Russell MJ. Low-tar medium nicotine cigarettes: a new approach to safer smoking. BMJ 1976;1:1430–3
  • 10. Smokeless tobacco Tobacco based Pure nicotine based Heated aerosol Unheated Vaping products Heated tobacco products “Heat-not-burn” Items are not shown to scale Oral nicotine products 10
  • 11. Royal College of Physicians – on relative risk "Although it is not possible to precisely quantify the long- term health risks associated with e-cigarettes, the available data suggest that they are unlikely to exceed 5% of those associated with smoked tobacco products, and may well be substantially lower than this figure". 11 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
  • 12. Department of Health (England) – on relative risk September 2022 12 McNeill et al. Nicotine Vaping in England, 2022 “…vaping poses only a small fraction of the risks of smoking”
  • 13. Much lower Much lower Much lower Much lower Much lower Much lower The strongest evidence for reduced harm is reduced exposure 13 Shahab L, Goniewicz ML, Blount BC, et al. Nicotine, Carcinogen, and Toxin Exposure in Long-Term E-Cigarette and Nicotine Replacement Therapy Users. Ann Intern Med 2017
  • 14. Evidence from randomised controlled trials 14 “There is high‐certainty evidence that e- cigarettes with nicotine increase quit rates compared to NRT”
  • 15. Evidence for beneficial population effect ‘triangulates’ • Also, user testimony • And… it is what you would expect!! 15 Professor Robert West, UCL. Presentation at SRNT-Europe 2019
  • 16. Regulation for tobacco harm reduction 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 16
  • 17. The public health mechanism 17
  • 18. Royal College of Physicians – perverse unintended consequences 18 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
  • 19. …if a risk-averse, precautionary approach makes e-cigarettes: • less easily accessible • less palatable or acceptable • more expensive • less consumer friendly • pharmacologically less effective • inhibits innovation … …then it causes harm by perpetuating smoking. Royal College of Physicians – perverse unintended consequences 19 Royal College of Physicians. Nicotine without smoke: tobacco harm reduction London: RCP; 2016.
  • 20. 1. Prohibition of vaping and other smokefree products
  • 21. 1. Prohibition of vaping and other smokefree products “Dr Harsh Vardhan received the award for spearheading the Government of India’s legislation to ban e-cigarettes and heated tobacco products in 2019.”
  • 22. 1. Prohibition of vaping and other smokefree products 22 Today, the country is faced with a greater challenge, that of illegal traffic in tobacco and its products. So long as the demand within the country persists, it will continue to fuel the illicit market that has expanded since the ban of its sale in early 2000. Unfortunately, as studies indicate, Bhutanese youth are at the centre of this growing illegal trade in tobacco and its products. WHO Office Bhutan: The Big Ban: Bhutan’s journey towards a tobacco-free society, 2019
  • 23. 2. Banning e-liquid flavours 23
  • 24. 2. Banning e-liquid flavours Tobacco Fruit Dessert or pastry Choc, sweets Russell et al. vaping flavour preferences Russell C, et al. Changing patterns of first e-cigarette flavor used and current flavors used by 20,836 adult frequent e-cigarette users in the USA. Harm Reduct J. BioMed Central; 2018 24
  • 25. 2. Banning e-liquid flavours 25 • The intended outcome: abstinence from nicotine, vaping, smoking and any other vice • Using tobacco flavoured vape products instead of other flavoured products • Accessing flavoured vapes via an illicit supply chain (a black market) • Relapsing back from vaping to smoking – both teenagers and adults • Not switching from smoking to vaping and continuing to smoke • Continuing to smoke or to start smoking as an adolescent because parents or adult role models smoke instead of vaping • Using other tobacco or nicotine products – hand-rolling tobacco, smokeless tobacco, heated tobacco, or new nicotine pouches • Buying from foreign suppliers in person or via the internet and importing for personal use • Buying from foreign suppliers to resell to others through informal networks • Making and mixing their own flavours at home or buying or selling home-mixed flavours • Using vapes that are made to look tobacco flavoured but have other flavours • Using flavour agents for food, drink or aromatherapy for adding to unflavoured nicotine liquids • Using flavours made for vaping but ostensibly marketed for another purpose • Switching to cannabinoid (THC or CBD) vapes • Initiating smoking instead of initiating vaping • Adopting another risk behaviour that may be worse
  • 26. Friedman AS. A Difference-in-Differences Analysis of Youth Smoking and a Ban on Sales of Flavored Tobacco Products in San Francisco, California. JAMA Pediatrics. 2021 2. Banning e-liquid flavours Teenage smoking increased following an e-cigarette flavours ban in San Francisco Past-30-Day Smoking Trends Among High School Students Younger Than 18 Years
  • 27. 3. Banning advertising of vapes 27
  • 28. 3. Banning advertising of vapes 28
  • 29. 3. Banning advertising of vapes 29  Don’t be socially irresponsible  Don’t target or feature children  Don’t confuse e-cigarettes with tobacco products  Don’t make health or safety claims  Don’t make smoking cessation claims  Don’t mislead about product ingredients  Don’t mislead about where products may be use Set standards avoid bans
  • 30. 4. Fear-based warnings This product contains nicotine which is a highly addictive substance. 30 Required by EU Tobacco Products Directive 40/14/EU
  • 31. 4. Fear-based warnings “[Our findings] suggest that the TPD nicotine addiction e-cigarette health warning may reduce smokers' willingness to use, and likelihood of purchasing an e- cigarette.” 31 Cox S, et al Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative relative risk message on smokers’ willingness to use and purchase an electronic cigarette. Addict Behav Reports, 2018
  • 32. This product is likely to be at least 95% safer than smoking cigarettes No product is completely safe, but use of this product is much less harmful than smoking 4. Fear-based warnings 32
  • 33. 5. Taxing safer products
  • 34. 5. Taxing safer products • Reduce teen e-cigarette use by 2.7 percentage points, but that 2 in 3 teens who do not use e- cigarettes due to the tax would smoke cigarettes instead. • ….approximately a half million extra teenage smokers overall. • … raise the number of daily adult cigarette smokers by 2.5 million nationally and reduce adult e-cigarette users by a similar number. • For every e-cigarette pod eliminated by an e- cigarette tax, more than 5.5 extra packs of cigarettes are sold instead Congress: raise e-cigarette taxes to a level comparable to cigarette taxes…
  • 35. 5. Taxing safer products
  • 36. The solution: Risk-Proportionate Regulation Measure Cigarettes, hand-rolling tobacco and other combustibles Taxation Relatively high taxes Advertising Prohibit other than within trade Warnings Graphic warnings depicting disease Public places Legally mandated controls Plain packaging Yes Ingredients Control reward-enhancing additives Age restrictions No sales to under-21s Internet sales Banned Product standards Control risks and reduce appeal 36
  • 37. The solution: Risk-Proportionate Regulation Measure Cigarettes, hand-rolling tobacco and other combustibles Vaping, heated tobacco smokeless and oral nicotine Taxation Relatively high taxes Low or zero tax (sales tax only) Advertising Prohibit other than within trade Control themes and placement Warnings Graphic warnings depicting disease Messages encouraging switching Public places Legally mandated controls Up to the discretion of the owner Plain packaging Yes No Ingredients Control reward-enhancing additives Blacklist material health hazards Age restrictions No sales to under-21s No sales to under-18s Internet sales Banned Permitted with age controls Product standards Control risks and reduce appeal Control risks 37
  • 38. Regulations for tobacco harm reduction 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 4. Innovation (and its enemies) 38
  • 40. A technology transition - electricity
  • 41. Innovation and its enemies… “Claims about the promise of new technology are at times greeted with skepticism, vilification or outright opposition—often dominated by slander, innuendo, scare tactics, conspiracy theories and misinformation. “The assumption that new technologies carry unknown risks guides much of the debate. This is often amplified to levels that overshadow the dangers of known risks.” Juma C. Innovation and Its Enemies: Why People Resist New Technologies. Oxford, New York: Oxford University Press; 2016.
  • 42. Thankyou! Counterfactual clivedbates@gmail.com www.clivebates.com @clive_bates 1. The problem is smoking 2. Smoke-free alternatives 3. Policy and unintended consequences 4. Innovation (and its enemies) Regulation for tobacco harm reduction

Editor's Notes

  1. Vaping products Top row shows: 1st generation cig-a-likes 2nd generation ego or ‘pen’ type devices 3rd generation tanks / mods type Bottom row shows Large electronic hookah Small shisha pipes Electronic pipe … there are many other configurations Heated tobacco products – sometimes referred to as heat-not-burn to distinguish between combustible products Shows the iQOs, Ploom and Glo products Novel nicotine products - shows Nicoccino – a nicotine containing film Zonnic – a range of nicotine products – lozenges, gum etc Voke – a cold aerosol (approved but not marketed) Niorette – cross-over NRT Smokeless tobacco Snus Moist snuff Tobacco-based lozenge